Clinical Documentation Specialist

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

Job Description:

Primary Responsibilities:

• Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
• Documents findings in workflow tools, noting all key information used in the tracking process.
• Review medical record concurrently for documentation not yet in the record but supported by clinical indicators.
• Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.
• Implements and maintains system to assign delinquencies to records where queries are ignored.
• Uses appropriate querying templates to get needed documentation.
• Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries.
• Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on an individual basis with physicians
• Use data provided by managers, directors, and consulting team to take action on what is working well and areas of focus
• Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
• Adheres to and enlarges upon coding policies and procedures in accordance with AHIMA’s Code of Ethical Conduct and AHIMA’s Standards of Ethical Coding.

Required Qualifications:

• Current RN license
• Minimum of 5 years of clinical experience in an acute care setting.
• Previous CDI experience preferred
• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting 
• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues
• Knowledge of age-specific patient needs and the elements of disease processes and related procedures
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers
• Assertive personality traits to facilitate ongoing physician communication
• Working knowledge of inpatient admission criteria
• Ability to work independently in a time-oriented environment

Social/Environmental Requirements:

• Office environment.
• Computerized environment, with data entry performed 40% of the time, and intense visual concentration on paper records and video display 50% of the time.
• Searching and retrieval of records involved, including heavy lifting and carrying bundles of medical records.
• Walking to different areas of the hospital and medical building. 

FLSA Status:

Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled